ALS Algorithm Flashcards
What is the advantage of using the ALS algorithm?
- Rx to be delievered expediently
- Without protracted discussion
Key actions to improve survival in cardiac arrest:
- Early, high quality, uninterrupted chest compressions
- Early defibrillation for shockable rhythms
What is the ALS algorithm?
Recognition of cardiac arrest - Step 1:
- HAZARDS - Ensure the environment is safe; approach the pt.
- HELLO - Check for a response - Shake the pt’s shoulders & ask loudly: “Hello, Are you alright?”
- HELP - If they do not respond shout for help/pull the emergency buzzer & proceed to Step 2.
Recognition of cardiac arrest - Step 2:
- Assess for breathing & signs of life (take ≤ 10s).
- Turn the pt. onto their back
- Open airway - head tilt & chin lift
- Determine if the pt. is breathing normally:
- LOOK - chest movement
- LISTEN - breath sounds
- FEEL - air on your cheek
- Assess for a carotid pulse simultaneously
Recognition of cardiac arrest - Step 3 - If help has arrived:
- Start CPR
- Instruct the helper to the call resuscitation team (2222 if in-hospital, 999 if out-of-hospital)
- Helper to get the resuscitation equipment
Recognition of cardiac arrest - Step 3 - If help has NOT arrived & you’re alone:
- Leave pt. to get help
- Get resus equipment
- Return ASAP to start CPR
Performing CPR - Step 1:
- Place the heel of 1 hand in the centre of the chest with the other hand on top.
- Interlock your fingers
- Keep your arms straight
- Position shoulders vertically above the pt’s chest
- Compress to a depth of 5-6 cm.
- Allow the chest to recoil after each compression.
- Repeat at a rate of 100-120 min-1.
- Continue with a ratio of 30 chest compressions to 2 breaths
When to change person doing compressions to avoid fatigue?
- Change every 2 min
How to do compressions when airway secured/advanced airway in place?
- Continuous compressions wihtout pausing during ventilations
Ventilate at 10 breaths/min
What is the role of waveform capnography during CPR?
- Ensuring correct ETT placement
- Monitoring ventilation rate & avoiding hyperventilation
- ID ROSC during CPR - increase in end-tidal CO2
- Prognosticate during CPR
Monitoring during CPR:
- Clinical signs - breathing, eye opening, movements
- Pulse checks
- Heart rhythm
- End-tidal CO2 with waveform capnography
- Bloods - avoid finger pricks
- Invasive cardiac monitoring
- Focused US/echo
What principles to remember during CPR?
- Good quality compressions
- ID & Rx reversible causes
- Secure airway
- IV access
Performing CPR - Step 2:
- Attach the defibrillator ASAP
- Apply the self-adhesive pads beneath the R clavicle and the L-MAL.
- Minimise interruptions to chest compressions.
- As soon as the defibrillator is attached, perform a rhythm check.
Rhythm assessment - How to perform Rhythm check with AED?
- Follow the prompts
Rhythm assessment - How to perform Rhythm check with manual defibrillator:
- Pause chest compressions
- Observe the rhythm on the defibrillator screen
- Determine if shockable or non-shockable
- Take no longer than 5 s to do this
What are the shockable rhythms?
- VF
- Pulseless VT
What are the non-shockable rhythms?
- PEA
- Asystole
Characteristics of VF:
- Bizarre, irregular waveform
- No recognisable QRS complexes
- Random frequency & amplitude
- Uncoordinated electrical activity
Exclude artefact - movement/electrical interference.
Characteristics of pulseless VT:
- Broad complex rhythm
- Rapid rate
- Constant QRS morphology
check for a pulse.
Characteristics of PEA:
- Clinical features of cardiac arrest
- ECG normally associated with a palpable pulse
Conditions ass. w/ PEA:
- Hypovolaemia
- Tamponade
- Tension pneumothorax
- Massive PE
Characteristics of Asystole:
- Absent QRS
- Atrial activity (P waves) may persist
- Rarely a straight-line trace
Completely straight line - monitoring lead disconnected
Mx of shockable rhythms - AED:
- Follow the audio/visual instructions from the machine
Mx of shockable rhythms - Manual defibrillator:
- Apply self-adhesive pads while doing compressions
- Pause compressions (< 5 sec) for rhythm check
- Resume compressions immediately
- Warn all rescuers to “stand clear” expect one doing compressions
- Remove O2 as appropriate
- Select the appropriate energy on the defibrillator
- Press the charge button
- Once charged - instruct the rescuer doing chest compressions to “stand clear”
- When all rescuers are clear, deliver the shock
- After the shock - Immediate CPR
- Do not pause to reassess the rhythm or feel for a pulse
- Continue CPR for another 2-min cycle
- Continue to repeat the 2-min CPR cycle - rhythm check - defibrillation sequence if VF/pVT persists
- Prepare ADR 1 mg IV & Amiodarone 300 mg IV to be given after 3rd shock
- Give further ADR 1 mg IV after alternate shocks (about every 3-5 min)
What shock energy is needed?
- 1st shock - at least 150J
- Subsequent shocks - same or higher
If electrical activity compatible with a pulse is seen during a rhythm check, or the AED advises no shock is required or check for signs of life - If no signs of life are present:
- Continue CPR
- Switch to the non-shockable side of the algorithm.
If electrical activity compatible with a pulse is seen during a rhythm check, or the AED advises no shock is required or check for signs of life - If signs of life are present:
- Start post-resuscitation care.
Mx of non-shockable rhythms - AED:
If the AED advises no shock is required?
- Follow its prompts
- Continue CPR.
Mx of non-shockable rhythms - Manual Defibrillator:
If electrical activity compatible with a pulse is seen, check for a pulse and/or signs of life.
If no pulse and/or signs of life:
- Continue CPR
- Prepare ADR 1 mg IV/IO to be given as soon as access is achieved
- After 2-minutes of CPR, pause chest compressions briefly for rhythm check
If an organised rhythm is seen during a 2 min period of CPR - What to do?
- DO NOT interrupt compressions to palpate pulse
- Only stop compressions to palpate pulse when signs of life
If there is any doubt when doing pulse check - what to do?
1.Continue CPR
Sites for IO access in adults?
- Proximal humerus
- Proximal tibia
- Distal tibia
How to give drugs peripherally during CPR?
- Flush with 20 ml of fluid
- Elevate extremity for 10-20 sec
Mx of non-shockable rhythms - Manual Defibrillator:
If electrical activity compatible with a pulse is seen, check for a pulse and/or signs of life.
If VF/pVT is seen at the rhythm check, or the AED advises to deliver a shock:
- Switch to the shockable side of algorithm
Reversible causes of cardiac arrest - 4 Hs and 4 Ts
4Hs:
1. Hypoxia
2. Hypovolaemia
3. Hypothermia
4. HypoK/ hyperK/ hypoglycaemia/ hypoCa/ H ion excess (acidaemia)
4Ts:
1. Thrombosis - coronary / PE
2. Tamponade
3. Tension pneumothorax
4. Toxins
Rx - Hypoxia:
- Ensure airway is patent
- Ventilate the lungs using a self-inflating bag;
- Give high-flow 100% O2
- Don’t hyperventilate - reduces the coronary perfusion pressure and can worsen the outcome
Rx - Hypovolaemia:
- IVF
- Blood
Rx - Hypo/HyperK:
- HyperK - give calcium chloride followed by insulin/dextrose infusion.
- HypoK - replace
Rx - Hypothermia:
- Active re-warming techniques
- Cardiopulmonary bypass may be considered
Rx - Coronary Thrombosis:
- PCI
- Thrombolysis
What is the commonest cause of thromboembolic or mechanical circulatory obstruction?
- Massive PE
Rx - Pulmonary Thrombosis:
- Fibrinolysis
Rx - Tamponade:
- Needle pericardiocentesis or resuscitative thoracotomy
Rx - Toxin OD (inpatients):
- R/V of the pt’s drug chart may be helpful
Rx - Tension Pneumothorax:
- Early needle decompression (thoracocentesis)
- Followed by chest drain insertion is needed.
Signs of ROSC:
- Clinical - breathing, eye opening, movements
- Monitoring - sudden increase end-tidal CO2 or arterial BP waveform
What to do after Return of spontaneous circulation (ROSC)?
- Reasses pt. using ABCDE approach
- Aim for sats of 94-98%
- Aim for a normal PaCO2
- 12-lead ECG
- Rx any precipitating cause(s)
- Consider targeted temp Mx
Who should be the one discussing stopping CPR?
- Team leader
How to Dx death after unsuccessful resus attempt?
- Observe pt. for 5 min after stopping CPR
- Absent mechanical cardiac Fx - Absent central pulse / absent heart sounds
- Absent reflexes - pupillary / corneal/ motor response to supra-orbital pressure
- Supplementary features - Asystole on ECG/ absent flow on direct intra-arterial pressure monitor (A-line) / absent heart contractions on echo
Post resus event tasks to do:
- Ongoing care of pt.
- Documentation of resus
- Communication w/ relatives
- Post-resus debriefing - immediate & delayed
- Restock equipment & drugs
- Audit forms
